1. Field of the Invention
The present invention generally relates to Clinical Information Systems (CIS) and, more particularly, to computer implementation of Progress Notes (PNs) in an electronic patient chart.
2. Background Description
A patient's medical chart is a complex collection of all the relevant "facts" relating to the patient's health. This raw data can be quite voluminous, and this has led to efforts to manage the data with a computer rather than with paper. But just keeping track of the data is not enough, to be useful and illuminating to the health care professional, the data must be organized in familiar and predictable ways.
There is no universal standard for the organization of a medical chart, be it paper or electronic. However, certain paradigms have evolved in modern medical practice using the paper chart. These can serve as the starting point for the level of standardization which the computerized patient record demands. Two organizing principles stand out as useful approaches for making patient data more informative: clinical histories and Progress Notes (PNs).
"Clinical Histories" denote the grouping of patient data by its type, independent of the context in which the data was recorded. Refinements can include further sub-classification and sorting. For example, a medication history includes all medication data, but not laboratory data, even though certain medications may have been prescribed based on the results of certain laboratory tests. The medication history may be grouped by drug and sorted by date to make it more readable. Observe that it is only because the reader associates certain drugs with certain medical conditions that the medication history is useful for understanding the patient's problems and treatment. When several histories are considered together (e.g., medications, laboratory tests, procedures, family history, allergies), the experienced clinician can piece together a more complete picture of the patient's condition. The completeness of the record and the skill of the clinician combine to make the historical, data-centered view of the chart a useful clinical tool.
But the clinicians, and the health care enterprise, want more information. They want the context in which the data was generated. This context includes the relationships between medical facts and the thought processes involved in investigating, diagnosing, and treating medical conditions. The "Progress Note" or PN is the vehicle for capturing that context. In practice, the degree of structure evident in Progress Notes spans the continuum from unstructured stream-of-consciousness text, to highly structured machine-readable forms. Although most Progress Notes exhibit neither of these extremes, the reason for the polarization is clear: the content must be both expressive and searchable. A common approach is to record information as labeled, stylized, free text, optimized for visual scanning by clinicians, in one place, and selectively code certain information, optimized for processing by data analysts, in another place. With this scheme, neither the clinician nor the analyst has easy access to the complete picture.